Form Approved: O.M.B. No. 2127-0004

On                                , 199       ,                                   [MFR] decided that (a defect which relates to motor vehicle safety)(a noncompliance with Federal Motor Vehicle Safety Standard No.             ) exits in the motor vehicles listed below, and is furnishing notification to the National Highway Traffic Safety Administration in accordance with 49 CFR Part 573 Defect and Noncompliance Reports.

Date this report was prepared:

Furnish the manufacturer's identification code for this recall (if applicable):

1. Identify the full corporate name of the fabricating manufacturer of the vehicle being recalled. If the recalled vehicle is imported, provide the name and mailing address of the designated agent as prescribed by 49 U.S.C. §30164.

Identify the corporate official, by name and title, whom the agency should contact with respect to this recall.

Telephone Number:     Fax No.:  

Name and Title of Person who prepared this report.

Signed:

I.  Identify the Vehicle Models Involved in the Recall

2. Identify the Vehicles Involved in the Recall, for each make and model or applicable vehicle line (provide illustrations or photographs as necessary to describe the vehicle), provide:

Make(s):   Model Years Involved: Model(s):

Production Dates: Beginning: Ending:

VIN Range: Beginning: __________________ Ending: _________________

Vehicle Type: Bodystyle:

Descriptive information which characterizes/distinguishes the recalled vehicles from those model vehicles not included in the recall:  

Make(s):   Model Years Involved: Model(s):

Production Dates: Beginning: Ending:

VIN Range: Beginning: __________________ Ending: _________________

Vehicle Type: Bodystyle:

Descriptive information which characterizes/distinguishes the recalled vehicles from those model vehicles not included in the recall:  

Make(s):   Model Years Involved: Model(s):

Production Dates: Beginning: Ending:

VIN Range: Beginning: __________________ Ending: _________________

Vehicle Type: Bodystyle:

Descriptive information which characterizes/distinguishes the recalled vehicles from those model vehicles not included in the recall:  

Identify the approximate percentage of the production of all the recalled models manufactured by your company between the inclusive dates of manufacture provided above, that the recalled model population represents. For example, if the recall involved Widgets equipped with certain items of equipment from January 1, 1996 through April 1, 1997, then what was the percentage of the recalled Widgets of all Widgets manufactured during that time period.

II.  Identify the Recall Population

3. Furnish the total number of vehicles recalled potentially containing the defect or noncompliance.

Number of Vehicles

Model Year Potentially Involved

Total Number Potentially Affected by the Recall:                                                                      

4. Furnish the approximate percentage of the total number of vehicles estimated to actually contain the defect or noncompliance:

Identify and describe how the recall population was determined--in particular how the recalled models were selected and the basis for the beginning and final dates of manufacture of the recalled vehicles:

5. Describe the defect or noncompliance. The description should address the nature and physical location of the defect or noncompliance. Illustrations should be provided as appropriate.

Describe the cause(s) of the defect or noncompliance condition.

Describe the consequence(s) of the defect or noncompliance condition.

Identify any warning which can (a) precede or (b) occur.

If the defect or noncompliance is in a component or assembly purchased from a supplier, identify the supplier by corporate name and address.

Identify the name and title of the chief executive officer or knowledgeable representative of the supplier:

If the recall is for a defect, complete item 6, otherwise item 7.

6. With respect to a defect, furnish a chronological summary (including dates) of all the principle events that were the basis for the determination of the defect. The summary should include, but not be limited to, the number of reports, accidents, injuries, fatalities, and warranty claims.

7. With respect to a noncompliance, identify and provide the test results or other data (in chronological order and including dates) on which the noncompliance was determined.

V.  Identify the Remedy

8. Furnish a description of the manufacturer's remedy for the defect or noncompliance. Clearly describe the differences between the recall condition and the remedy.

Clearly describe the distinguishing characteristics of the remedy component/assembly versus the recalled component/assembly.

Identify and describe how and when the recall condition was corrected in production. If the production remedy was identical to the recall remedy in the field, so state. If the product was discontinued, so state.

VI.  Identify the Recall Schedule

Furnish a schedule or agenda (with specific dates) for notification to other manufacturers, dealers/retailers, and purchasers. Please, identify any foreseeable problems with implementing the recall.

VII.  Furnish Recall Communications

9. Furnish a final copy of all notices, bulletins, and other communications that relate directly to the defect or noncompliance and which are sent to more than one manufacturer, distributor, or purchaser. This includes all communications (including both original and follow-up) concerning this recall from the time your company determines the defect or noncompliance condition on, not just the initial notification. A DRAFT copy of the notification documents should be submitted to this office by Fax (202-366-7882) for review prior to mailing.

Note that these documents are to be submitted separately from those provided in accordance with Part 573.8 requirements.

1. ¹Each manufacturer must furnish a report, to the Associate Administrator for Safety Assurance, for each defect or noncompliance condition which relates to motor vehicle safety.

This guide was developed from 49 CFR Part 573, "Defect and Noncompliance Reports" and also outlines information currently requested. Any questions, please consult the complete Part 573 or contact Mr. Jon White at (202) 366-5227 or by FAX at (202) 366-7882.